Nicotine Dependence Program
Up in Smoke: Mission Health Nicotine Dependence Program Aims to Erase Regional Toll of Tobacco Addiction with Progressive Prevention Education and Cessation Counseling Tobacco has a long and complicated history in North Carolina. Whether burley or flue-cured, the leaf became the most powerful cash crop in Western North Carolina from the late nineteenth century through the 1970s. Farmers enjoyed profit increases from the crop, and tobacco use surged as soldiers returned home from the Civil War. Thus, an addiction was born that residents have struggled to break through present day. Nicotine dependence remains a substantial societal burden. Smoking and chewing tobacco is definitively linked to serious diseases such as cancer, heart disease, stroke, emphysema and chronic obstructive pulmonary disease (COPD), among other debilitating illnesses. 90% of COPD deaths are caused by smoking alone. In addition, tobacco use and its accompanying national healthcare costs are staggering: Tobacco costs the United States $170 billion annually in direct medical expenses for adults and $156 billion on lost productivity. Mission Health is heavily invested in helping community members quit smoking. The mission of the cessation program has two urgent goals: to help current tobacco users quit, and to prevent non-tobacco users from starting.
Tobacco’s Toll on Our Nation's Health The Centers for Disease Control declared that tobacco use is the single most preventable cause of disease and death in the United States. Below are a few alarming disease and mortality-related statistics about tobacco use and its effects in the United States: • 480,000 deaths can be attributed to tobacco use in the United States, and 41,000 of these deaths are due to secondhand smoke exposure. For each death related to tobacco use, there are 20 sufferers of tobacco-related illnesses. • Tobacco use contributes significantly to the cancer death rate – 80% for women and 90% for men, as well as an 86% increase in cancer recurrence risk for patients who are diagnosed with early stage lung cancer. • Cancer patients who smoke and are undergoing t reatment have higher levels of treatment-related toxicity, increased radiation-related complications, and reduced beneficial effects from treatment. Other smoking-related problems for this group include slower wound healing after oncology surgery, longer post-surgery hospitalizations, higher infection rates, and pulmonary problems. • Women who smoke while pregnant experience more premature births, stillbirths, and infant deaths, in addition to delivering babies with lower birth weights. • Even non-tobacco users can’t escape its detrimental effects. Secondhand smoke is linked to severe asthma, respiratory infections, ear infections, and Sudden Infant Death Syndrome (SIDS) in babies and children. Nicotine Dependence Program
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Given tobacco’s highly addictive qualities, many patients struggle to quit smoking even after a cancer diagnosis, thereby lowering future quality of life and rate of survival. Tobacco users often try and fail to quit smoking or using tobacco, trapping them in an unhealthy cycle of dependence. Tobacco dependence disorder is a chronic relapsing disease, and thus, should be treated as such in order to help users break free from the addiction.
Tobacco’s Many Forms: Targeted and Numerous Choices for Consumers Nicotine can be delivered through a multitude of methods, thereby increasing its appeal to consumers of various ages and socio-economic levels. The most popular nicotine delivery systems include: • • • • •
Traditional cigarettes E-cigarettes or vaping products Smokeless or chewing tobacco Pipes Cigars
With an increase in these types of nicotine delivery (traditional cigarettes, e-cigarettes, etc.) available over the last 20 years, an equally sophisticated and comprehensive approach to raising community awareness about cessation must be pursued. This includes, but is not limited to, community education, marketing, and outreach programs for schools, churches, professional associations, and civic organizations.
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The Mission Health Nicotine Dependence Program Mission Health’s patients need a great deal of support to quit using tobacco, and the need for patient assistance is increasing each year. In 2013, 525 Mission Health cancer patients were smokers. The number rose to 581 the following year, a trend that Nicotine Dependence Program staff are working steadily to reverse. The Mission Health Nicotine Dependence Program meets each tobacco user wherever they are in their cessation journey – whether very resistant to quitting, highly motivated, or somewhere in between. Cessation services are available to inpatients, outpatients, and all Mission Health team members and their families. Every patient at Mission Health inpatient and outpatient clinics is asked about his tobacco use, advised to quit, and given resources to assist him in the quitting process. Smoking cessation counselors employ a panoply of psychological and physiologically-based techniques to educate, guide, and compassionately advocate for patients who wish to quit, but continue to struggle. Smoking cessation services offer hope to smokers, potentially lowering the rate of hospitalizations, while saving Mission Health nearly $700,000 annually. Furthermore, with the advent of nonsmoking workplaces and public spaces in the United States in the last 25 years, cessation not only improves patient outcomes, but makes for a healthier workplace and community. The Mission Nicotine Dependence Program is both patient-centered and comprehensive. Moving forward, it aims to provide direct and continuous support to SECU Cancer Center Patients from diagnosis through treatment and, ideally, successful cessation. Program components include: • Assistance designed for different learning styles • Adolescent cessation education for smoking and chewing tobacco, as well as prevention • Cancer prevention programming, including tobacco-free education, to improve health outcomes and support the Cancer Center retain patient-centered care accreditation from the Commission on Cancer • Counseling to patient family members who are also smokers • Meeting smokers “where they are” – whether open to cessation counseling with goals of quitting, or are not yet emotionally ready to quit • Developing a pathway for continuous support for cancer patients beginning at time of diagnosis • Constructing plans to provide Nicotine Replacement Therapy to all patients through Mission Health retail pharmacies, and making NRT available to uninsured patients at discharge to facilitate cessation efforts started during hospitalization Designers of the Nicotine Dependence Program considered the demographics associated with tobacco use, as well as major health conditions presented in tobacco-using patients. When compared to the general population, smokers typically have lower educational attainment, weaker social support networks and lower socio-economic status. They are also less likely to be insured, and suffer from chronic diseases. This combination of factors puts them at high risk for hospital readmission, subsequently increasing hospital expenses. Tobacco cessation has proven to lower readmission rates and length of hospital stays, regardless of the reason for hospitalization. Nicotine Dependence Program
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Tobacco use is closely associated with the development of many chronic diseases. In examining major health conditions for tobacco-using patients, the Mission Health units most impacted by tobacco use are the following: • 62% of the COPD inpatient population use tobacco • 32% of the oncology inpatient population use tobacco • 30% of the heart failure inpatient population use tobacco • 10% of the pregnant inpatient population use tobacco • 42% of the behavioral health inpatient population use tobacco (Tobacco cessation is related to long-term sustained abstinence from drugs and alcohol.) Widespread nicotine dependence across the health system affects how we care for our patients and the rates at which they are hospitalized and readmitted. Western North Carolina has a current smoker rates of 22.8%, which is significantly higher than the statewide rate of 19.1%, and the national rate of 16.8%. The Nicotine Dependence Program has the potential to transform this statistic. The Healthy People 2020 program, a national health promotion and disease prevention initiative, has a goal of lowering the regional smoking rate to 12%. To reach this level, 82,050 individuals would need to enter the cessation program, and Mission Health would simultaneously need to make considerable progress to prevent nonsmokers from becoming addicted.
John, a graduate of the Mission Health Nicotine Dependence Program, has quit using tobacco successfully and praises both his counselor and the program framework. However, a smoker’s intimate relationship with tobacco for comfort and stress relief cannot be minimized. As many smokers express, John explained that while he wanted to quit, he hadn’t been able to. “The scary part to me is to give up something I’ve known my whole life… but Mission’s Nicotine Cessation staff have been fabulous. Once I decided to do it, they became a real asset in terms of strategies,” he shared. He explained that going through the Nicotine Cessation program not only helped him meet his long-term goal of quitting, but now he feels great and no longer has the desire to smoke. “Being held accountable was a big part of my success… I did this for me, because I had to,” he said. There is no doubt that the best-practice-based approach and relationships forged between the Nicotine Dependence Program staff and patients form solid foundations that cessation is built upon. The talented and compassionate Mission Health cessation counselors fill numerous roles in a patient’s journey to quit – from teacher to cheerleader, counselor to friend. It’s critical that tobacco counselors at Mission Health communicate to smokers that counseling is a judgment-free partnership. Counselors complement this philosophy with interactive strategies, such as motivational interviewing, to empower the patient. Likewise, these counselors are culturally attuned to the Appalachian culture and accompanying tobacco traditions in Western North Carolina. In short, counselors respect where their patients come from both culturally and psychologically; this comprehension is vital to a patient’s success. The Mission Health Nicotine Dependence Program (NDP) is comprised of two full-time and one parttime staff who are trained cessation specialists, licensed counselors, or certified health coaches. They provide both inpatient and outpatient cessation counseling to patients who willingly embrace cessation, and even to those who are resistant. The team also trains area providers and Mission Health staff in tobacco cessation topics so services can be shared with patients and employer groups, respectively. Outpatient cessation counseling is also promoted to Mission Health employees. Nicotine Dependence Program
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The innovative Nicotine Dependence Program would be greatly boosted by community investment, helping maintain the program’s stellar reputation and progressive framework. Supporters of an expanded and enhanced Mission Health Nicotine Dependence Program would measurably improve and amplify the program, as well as make it available to more community members. Proposed improvements include: • An embedded resource at the SECU Cancer Center, dedicated to supporting tobacco users diagnosed with Cancer throughout their treatment and recovery • Making access to Nicotine Replacement Therapy easier, especially by offering it at-cost and over the counter for those in need • Raising awareness about the tobacco cessation program and coordinating with other Mission departments, including respiratory therapy, discharge planning, intake processes, physicians, and IT • Encouraging changes to the electronic medical records system to improve nicotine cessation program delivery to patients • Reaching more patients through Mission Health staff programs, such as the Mission Health Accountable Care Organization, Care Management Services, Caramedics, and Healthy State (a new insurance product) • Providing more and better cessation services for the outpatient community through a solid cessation community infrastructure (i.e., providing tobacco cessation certification training for 50 individuals both inside and outside the health system through a partnership between Mission Health and the Duke-University of North Carolina Tobacco Treatment Specialist Certification Program to make cessation services more widely available) • Reinvigorating and incorporating youth prevention programs across the entire region (North Carolina stopped funding youth tobacco prevention programs entirely.) • Raising awareness and increasing outreach for youth asthma • Improving mine-able data, automated reporting, and data placement flow via the IT department • Ensuring the Results Based Accountability process guarantees tobacco use and cessation metrics at system and community levels • Training staff on billing or services, and ensuring compatibility between infrastructure and billing strategies • Continuing work between the Nicotine Dependence Team and Copestone (Mission Health’s inpatient behavioral health provider) and care teams who focus on diseases such as COPD • Developing a cessation program at all member hospitals in the health system so every patient is assessed for tobacco use and advised to quit, then assisted in quitting • Working effectively with patients across all stages of quitting • Erasing problems posed by logistics and location with the use of tele-health capabilities
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Programmatic Financial Needs To be most effective and provide the most community value, funds for growing the Nicotine Cessation program are as follows (2016 costs included): 2016 Program Components
2016 Operating Expenses
Cessation Counselors’ Salaries/Benefits Marketing Materials
$161,850 $2,000
2017 Program Components
2016 Operating Expenses
Cessation Counselors’ Salaries/Benefits Marketing Materials
$161,850 $2,000
2018 Program Components
2018 Operating Expenses
Two additional FTEs to support inpatient/telehealth
$409,792
Marketing Materials
$5,000
Office Supplies and Two Computers
$6,000
Medication Assistance (600 patients, approximately $50 for two-week supply of nicotine patches)
$30,000
Capital Request (to build out office space for private counseling)
$40,000
Another way to analyze the program’s finances and sustainability is to calculate the average cost of each cessation attempt. On average, each quitting attempt comes to $350 per patient, which includes two weeks’ worth of bridge medication. Each Nicotine Dependence Program full-time employee can assist approximately 300 patients each year, equaling roughly $135,000 in patient care annually. Currently, the Nicotine Dependence Program is subsidized by Mission Health’s general funds, and the program absorbs most of its operating costs. While producing revenue is a common financial goal, this program avoids expenses in the long run by improving the overall health of the community, healthcare costs subsequently decrease as the program’s effects take hold.
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The department has developed a tracking system based on the Results Based Accountability framework, which quantifies: • The number of referrals made • The number of lives saved • Information on medication assistance given • The number of counselors and providers trained • Evaluation tools, including a satisfaction survey and referral numbers • Quality of life assessments using cessation success data, quality oflife metrics, hospital readmission data, and tobacco-related illness reduction • Cessation offers made and received, and overall efficiency statistics (thereby increasing EMR capabilities) • Behavioral health measures as part of the Joint Commission – especially important as more inpatient services are offered in Western North Carolina • Target populations measuring inpatients identifying as tobacco users during intake, and outpatients with goals of quitting use within 30 days • Target populations that measure cessation counseling training – i.e., those who provide regional cessation services to diverse populations (thereby creating a support network for patient communities) • Community reports on provided services (led by trained cessation counselors) to remain accountable and results-based We are in the initial stages of a partnership with the Mission Health Chronic Condition Clinic to bill for services, which launches in FY17. While revenue will likely come from Medicare, NC Medicaid, and private commercial insurance companies, the reimbursement rate only provides a portion of the support necessary for the program to be self-sustaining. The most important factor in program sustainability is the long-term impact on community health. Currently, healthcare expenses average $2,672 per smoker each year in North Carolina. By improving the health of our community, these patient costs are reduced, as are costs for our health system at large. Regional success is indirectly related to our ability to help tobacco addicts cease use and become healthier members of society.
Through a combination of compassion, innovation, and generous community investment, the vision for the Mission Health Nicotine Dependence Program can be realized, and our community members can begin leading healthier lives. As Laurie Stradley, Director of Wellness at Mission Health, states, "Our biggest hope is that eventually cessation support will no longer be necessary at all." With your support, we can grow closer to reaching this goal.
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